Complaint Investigation Report

It is alleged that R1 was admitted to facility on 4/19/2024 and required insulin and that it was not ordered by facility until 05/14/2024. LPA interviewed eight (8) residents and seven (7) of (8) residents could not collaborate the allegation. LPA interviewed five (5) staff and three (3) of five (5) staff stated they did not know because medications are not within their scope of work. S1 stated the medication was ordered on 4/19/2024 and they were waiting on doctors orders. No documentation was provide to support statement. One (1) staff stated that R1 medication was not ordered until 05/14/2024 and could not explain why. LPA reviewed R1 doctor's orders and the order form shows that the medication was ordered on 05/14/24 with a start date of 05/15/2024. The resident went with out medication for 25 days.

Allegation: Staff did not assist resident to perform their glucose testing. It is alleged that facility did not provide resident with glucose meter until 25 days from admission.

The investigation revealed: Review of documentation and medical records indicate that resident was admitted to facility on 04/19/2024 and resident arrived without a glucose meter. Resident's glucose meter arrived the same day (05/15/2024) as the medication according to S1. Facility failed to assist resident in testing R1 glucose for 25 days.

Based on record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Kathleen McDonald, Wellness Director A copy of the report and appeal rights were issued.